SampleCompletedSummaryofCoverage
http://naic.org/documents/committees_b_consumer_information_hhs_dol_submission_1107_soc_populated.pdf
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Insurance Company 1: PPO Plan 1 Policy Period: 1/1/2011 – 12/31/2011
Summary of Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO
Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.
If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov.
This is not a policy. You can get the policy at www.insurancecompany.com/PLAN1500 or by calling 1-800-XXX-XXXX.
A policy has more detail about how to use the plan and what you and your insurer must do. It also has more detail about your coverage and costs.
Important Questions Answers Why this Matters:
What is the premium?
$481 monthly
The premium is the amount paid for health insurance. This is only an estimate based on
information you’ve provided. After the insurer reviews your application, your actual
premium may be higher or your application may be denied.
What is the overall
deductible?
$2,500 person /
$7,500 family
Doesn’t apply to preventive care
You must pay all the costs up to the deductible amount before this health insurance plan
begins to pay for covered services you use. Check your policy to see when the deductible
starts over (usually, but not always, January 1st). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific
services?
Yes; $300 for pharmacy
expenses
You must pay all of the costs for these services up to the specific deductible amount before
this plan begins to pay for these services.
Is there an out–of–
pocket limit on my
expenses?
Yes. $2,500 person /
$7,500
family
The out-of-pocket limit is the most you could pay during a policy period for your share of
the cost of covered services. This limit helps you plan for health care expenses.
What is not included in
the out–of–pocket
limit?
Co-payments, premium,
balance-billed charges,
prescription drugs, and health
care this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit. So,
a longer list of expenses means you have less coverage.
Is there an overall
annual limit on what
the insurer pays?
No.
The chart starting on page 2 describes any limits on what the insurer will pay for specific
covered services, such as office visits.
Does this plan use a
network of providers?
Yes. See
www.insurancecompany.com
for a list of participating doctors
and hospitals.
If you use an in-network doctor or other health care provider, this plan will pay some or
all of the costs of covered services. Plans use the term in-network, preferred, or
participating for providers in their network.
Do I need a referral to
see a specialist?
No. You don’t need a referral to
see a specialist
You can see the specialist you choose without permission from this plan.
Are there services this
plan doesn’t cover?
Yes.
Some of the services this plan doesn’t cover are listed in the “Excluded Services & Other
Covered Services” section.
2 of 6
Insurance Company 1: PPO Plan 1 Policy Period: 1/1/2011 – 12/31/2011
Summary of Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO
Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.
If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov.
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. You pay this plus
any deductible amounts you owe under this health insurance plan. For example, if the health plan’s allowed amount for an overnight hospital
stay is $1,000 and you’ve met your deductible, your co-insurance payment of 20% would be $200. If you haven’t met any of the deductible
and it’s at least $1,000, you would pay the full cost of the hospital stay.
The plan’s payment for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed
amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and co-insurance amounts.
Common
Medical Event
Services You May Need
Your cost if you use a
Limitations & Exceptions
Participating
Provider
Non-
Participating
Provider
If you visit a health
care provider’s office
or clinic
Primary care visit to treat an injury or illness $35 co-pay/visit 40% co-insurance –––––––––––none–––––––––––
Specialist visit $50 co-pay/visit 40% co-insurance –––––––––––none–––––––––––
Other practitioner office visit
20% co-insurance
for chiropractor
and acupuncture
40% co-insurance
for chiropractor
and acupuncture
–––––––––––none–––––––––––
Preventive care/screening/immunization $0 40% co-insurance
If you have a test
Diagnostic test (x-ray, blood work) 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
Imaging (CT/PET scans, MRIs) 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
If you need drugs to
treat your illness or
condition
More information
about drug coverage is
at
www.insurancecompa
ny.com/prescriptions.
Generic drugs
$10 co-pay (retail);
$10 co-pay (mail
order)
40% co-insurance
Covers up to a 30-day supply (retail
prescription); 31-90 day supply (mail
order prescription)
Preferred brand drugs
20% co-insurance
(retail and mail
order)
40% co-insurance –––––––––––none–––––––––––
Non-preferred brand drugs
40% co-insurance
(retail and mail
order)
60% co-insurance –––––––––––none–––––––––––
Specialty drugs (e.g., chemotherapy) 0% co-insurance –––––––––––none–––––––––––
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Insurance Company 1: PPO Plan 1 Policy Period: 1/1/2011 – 12/31/2011
Summary of Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO
Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.
If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov.
Common
Medical Event
Services You May Need
Your cost if you use a
Limitations & Exceptions
Participating
Provider
Non-
Participating
Provider
If you have
outpatient surgery
Facility fee (e.g., ambulatory surgery center) 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
Physician/surgeon fees 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
If you need
immediate medical
attention
Emergency room services 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
Emergency medical transportation 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
Urgent care 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
If you have a
hospital stay
Facility fee (e.g., hospital room) 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
Physician/surgeon fee 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health outpatient services 0% co-insurance 40% co-insurance After 8 visits, not covered.
Mental/Behavioral health inpatient services 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
Substance use disorder outpatient services 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
Substance use disorder inpatient services 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
If you become
pregnant
Prenatal and postnatal care Not Covered Not Covered –––––––––––none–––––––––––
Delivery and all inpatient services Not Covered Not Covered –––––––––––none–––––––––––
If you have a
recovery or other
special health need
Home health care 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
Rehabilitation services 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
Habilitation services 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
Skilled nursing care 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
Durable medical equipment 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
Hospital service 0% co-insurance 40% co-insurance –––––––––––none–––––––––––
If your child needs
dental or eye care
Eye exam Not Covered Not Covered –––––––––––none–––––––––––
Glasses Not Covered Not Covered –––––––––––none–––––––––––
Dental check-up Not Covered Not Covered –––––––––––none–––––––––––
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Insurance Company 1: PPO Plan 1 Policy Period: 1/1/2011 – 12/31/2011
Summary of Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO
Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.
If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov.
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy for others.)
Bariatric surgery
Non-emergency care when traveling outside
the U.S.
Cosmetic surgery
Dental care (Adult)
Infertility treatment
Long-term care
Private-duty nursing
Routine eye care (Adult)
Routine foot care
Routine hearing tests
Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy for other covered services and your costs for these services.)
Acupuncture
Chiropractic care
Hearing aids
Your Rights to Continue Coverage:
You can keep this insurance as long as you pay your premium unless one or more of the following happens:
you commit fraud
the insurer stops offering services in the state
you move outside the coverage area
Your Grievance and Appeals Rights:
A grievance is a complaint you have about your health insurer or plan. You have the right to file a written complaint to express your
dissatisfaction or denial of coverage for claims under this health insurance. Call 1-800-XXX-XXXX or visit www. Xxxxxxxxxxxxxx.com.
An appeal is a request for your health insurer or plan to review a decision or a grievance again. For more information on the appeals process, call
your state office of health insurance customer assistance at: 1-800-XXX-XXXX or visit www. Xxxxxxxxxxxxxx.gov.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
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Insurance Company 1: PPO Plan 1 Policy Period: 1/1/2011 – 12/31/2011
Coverage Examples Coverage for: Individual + Spouse | Plan Type: PPO
Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.
If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov.
Having a baby
(normal delivery)
About these
Coverage
Examples:
These examples show how this
plan might cover medical care in
three situations. Use these
examples to see, in general, how
much insurance protection you
might get from different plans.
Amount owed to providers:
$10,000
Plan pays $0
You pay $10,000 (maternity is
not covered, so you pay 100%)
Sample care costs:
First office visit $100
Radiology $300
Laboratory tests $200
Routine obstetric care $2,000
Hospital charges
(mother)
$4,100
Hospital charges
(baby)
$1,900
Anesthesia $1,000
Circumcision $200
Vaccines, other
preventive
$200
Total $10,000
You pay:
Deductibles $0
Co-pays $0
Co-insurance $0
Limits or exclusions $10,000
Total $10,000
Amount owed to providers:
$98,000
Plan pays $94,800
You pay $3,200
Sample care costs:
Office visits &
procedures
$4,000
Radiology $4,000
Laboratory tests $2,400
Hospital charges $3,300
Inpatient medical care $200
Outpatient surgery $3,400
Chemotherapy $64,000
Radiation therapy $13,000
Prostheses (wig) $500
Pharmacy $2,000
Mental health $1,200
Total $98,000
You pay:
Deductibles $2,500
Co-pays $200
Co-insurance $0
Limits or exclusions $500
Total $3,200
Amount owed to providers:
$7,800
Plan pays $6,800
You pay $1,000
Sample care costs:
Office visits &
procedures
$960
Laboratory tests $300
Medical equipment &
supplies
$40
Pharmacy $6,500
Total $7,800
You pay:
Deductibles $300
Co-pays $260
Co-insurance $400
Limits or exclusions $40
Total $1,000
Treating breast cancer
(lumpectomy, chemotherapy,
radiation
)
Managing diabetes
(routine maintenance of existing
condition
)
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care also will be
different.
See the next page for
important information about
these examples.
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Insurance Company 1: PPO Plan 1 Policy Period: 1/1/2011 – 12/31/2011
Coverage Examples Coverage for: Individual + Spouse | Plan Type: PPO
Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.
If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov.
Questions and answers about Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
Costs don’t include premiums.
Sample care costs are based on national
averages supplied to the U.S. Department
of Health and Human Services (HHS),
and aren’t specific to a particular
geographic area or health plan.
Patient’s condition was not an excluded or
preexisting condition.
All services and treatments started and
ended in the same policy period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from in-
network providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles, co-
payments, and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for these
conditions could be different, based on
your doctor’s advice, your age, how serious
your condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples
to compare plans?
Yes. When you look at the Summaries of
Coverage for other plans, you’ll find the
same coverage examples. When you
compare plans, check the “You Pay” box
for each example. The smaller that
number, the more coverage the plan
provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-of-
pocket costs, such as co-payments,
deductibles, and co-insurance. You also
should consider contributions to accounts
such as health savings accounts (HSAs),
flexible spending arrangements (FSAs) or
health reimbursement accounts (HRAs)
that help you pay out-of-pocket expenses.
